Thursday, December 10, 2009

Controlled Drug E-Prescriptions: Policy Versus Practice

"Well it's about that prescription you gave to Mr. Pacertoday for Norco."

"What about it?"

"Well, it's not printed on the right controlled drug presciption paper."

"But that's how we've been issuing prescriptions. I haven't seen any of that special printer paper with that squiggly-lined paper for months. I know we're 'sposed to use in that kind of paper, but it's never in the printer and there's no special printer for controlled drugs, so we just use regular paper. It has my signature, right?"

"Well, there's a signature, but I really can't tell if this is an authorized signature without the proper paper..."

"But you're talking to me, right?"

"Uh, yeah."

"And you called my office phone number, right?"

"Uh, yeah."

"So can you fill the prescription now that you've verified that I'm the one who wrote the prescription?"

"Well, I'm really not supposed... Well, I will this time. But in the future, make sure you use the right paper, okay?"

No, not okay.

Doctors, nurses, and secretaries do not have time to fill special paper in printers to write prescriptions for controlled drugs, yet this is what our fabulous regulators require in order to prevent Medicare fraud. Practically speaking, this isn't happening for the simple fact that it's impractical.

How about just allowing us to send our controlled drug script electronically, like all of the other prescriptions we send? Or maybe add an encoded PIN number?

Using fully implemented e-prescribing would likely have much less potential for fraud and abuse...

..unless, of course, our electronic medical record systems aren't as secure as the bureaucrats say they are.

14 comments:

Anonymous
said...

Medicare has rules - you break those rules, you don't get paid. We break those rules, we don't get paid. On top of not getting paid, we can all get fined.

With Medicare, you can call in rxs or print them. If you print them, they must be on secure paper. If you don't have another printer, buy one - they're cheap. Or - here's an idea - use secure paper for ALL your rxs - what's the downside? Your excuses are irrational.

Depending on the state, you can't send an e-rx for a controlled substance at all. I could tell you all the reasons why, but the complete arrogance of your post indicates you have no respect for the requirements of other professions (this particular one came from fradulent rxs written by prescribers who feel just as you do, btw). It may not be complicated heart issues, but it is a daily issue for those of us who are pharmacists.

Following rx requirements is something you should have learned before you finished residency. It reflects poorly on you that you would ask a fellow health professional to bend/break the rules just because you don't like them or can't think of a way to comply.

Everyone likes to point fingers about Medicare fraud, but no one likes to follow the rules to prevent it. You, sir, are one of those who think they are above the rules!

Everyone likes to point fingers about Medicare fraud, but no one likes to follow the rules to prevent it. You, sir, are one of those who think they are above the rules!

While the intent is understandable, the expense and practicality of implementing special paper in real life is not as simple as our regulators would have us believe.

Please come to our hospital system's four hospitals with its hundreds of patient care areas, both inpatient and outpatient, and request that two printers be installed at each nurses station, clinic space, and patient care area so that one printer will be dedicated to printing patient instructions, medication lists, and orders on plain paper and the other printer used only for prescriptions, as required and referenced in this "arrogant" post.

I work in the SF Bay area - loaded with hospitals large and small. They all seem to get it - everything is printed on the same paper - secure pape purchased from approved vendors.

Why is it that CA hospitals & large cliics (think Kaiser & all its attending facilities) can do it & you can't? Seriously, CA is in a huge fiscal crisis, but UCSF, Stanford, Packard Childrens, Oakland Childrens, SF General can all get this done.

Buy the right paper & printers & your needs are solved. The rules have been out there for years with a long advance start date. The capital budgets should have been in place for the printer updates & the operating budgets should have been in place for the correct paper.

Tell me - how many heart related gadgets have you & your colleagues come up with to buy in the 5 years these rules have been in place?

Yeah - lots I'll bet. I have no sympathy when you get bothered by pharmacists who insist you comply with Medicare rules. You chose & still choose to make excuses when just changing & adapting is all that is needed. Get creative & in compliance! None of us is willing to get fined because its just too much work for you - get over yourself!

C'mon, Doc, the guy's right. You gotta play by the rules. If doctors, nurses and secretaries decided they simply had to MAKE the time, they'd find a practical way to comply.

For my money, maybe people should just be able to buy whatever drugs they want over the counter. Who needs a doctor's prescription?

Oh, but that would kind of cut you right out of the loop, wouldn't it? What part of your income would you lose if you didn't get paid for writing prescriptions? Maybe what it all points to is, THE BUSINESS OF MEDICINE IS IMPRACTICAL.

My beef here is not with the pharmacist - he was, after all, following the rules. The beef is the fact that in this electronic era, we're still requiring the use of paper, (worse, special paper) for controlled drugs, while other potentially equally dangerous drugs do not have this requirement.

While written prescriptions will remain required in certain circumstances and a few special locations to print them are easily established, it remains wasteful to think we cannot, in this day and age, reach a reasonable consensus on how to send a controlled drug prescription electronically to a pharmacy.

In this electronic age, your electronic prescription to me does indeed print out an actual hard copy rx on my side. Each and every rx is still put on a PAPER copy, no matter you send it electronically, call it in or hand write it - its all put down on PAPER.

Those paper copies are stored for 10 years - yes, we must store them 10 years in a secure location.

The purpose behind the security paper for Medicare & controlled drugs is that the systems are easy to hack. After all, who does the rx inputing in all those patient care areas? Not physicians I can tell you that! Otherwise, I wouldn't get such nonsenical prescriptions or rxs for drugs that haven't been on the market for 8 years, but are still on your drop down menu.

Now - as to the fraud part......it is very, very easy to duplicate any medical systems letterhead & find any prescribers NPI & DEA numbers. These electronic rxs can be sent from anyone's home - and they have been. Don't for one minute think these systems are as secure as touted!

However, only certain people (prescribers) and systems (hospitals & clinics) are able to purchase security paper from vendors and there are only about 10 vendors nationwide.

Now, it becomes more difficult to forge or hack & send an electronic rx.

Are your patients trying to do this to get more HCTZ or Diovan? No - those are not the patients we're talking about. We're talking about Dr mills who "see" a hundred bussed in patients in a day (NOT) and write rxs for gabapentin, trazodone, lortab and .... yes Diovan. All of these have street value and have been paid for by the Medicare system. But, when a prescriber has been shut out of Medicare for abuse, he/she/they can no longer purchase the secure paper & it becomes easier for us on my end to stop the rxs from being filled and the contents being sold at flea markets or online. Where do you think these people get Diovan or Lipitor online in the US for low, low prices? Not at valid pharmacies I can assure you.

It may not sound like lots of money but it adds up to several millions of dollars. The bussing of Medicare patients has become common in areas of California to the extent these mills just move from place to place within weeks.

So - your argument of waste is irrelevant - on my end that rx still is on a piece of paper (sadly, erxs are on full 8 1/2 x 11 & your old rxs were 1/4 that size). The rx was on paper 100 years ago & it is still on paper now - just not on your end.

Now....can you perhaps see its not all about you? It is a part of healthcare which is expensivem but the implementation of secure rxs means it keeps the costly excess of Medicare fraud down. This is part of what we talk about when we want to cut down costs.

Now - just get on that committee, buy the printers or get your IT department to route all rxs to one printer on each floor (come on - there are about 4 on each floor - at least here in CA), order the correct paper & voila - you're now in compliance!

I want to point out how I believe one of the replies above supports what I believe Dr. Wes was trying to say:

"Why is it that CA hospitals & large cliics (think Kaiser & all its attending facilities) can do it & you can't? Seriously, CA is in a huge fiscal crisis, but UCSF, Stanford, Packard Childrens, Oakland Childrens, SF General can all get this done."

That's the whole problem. If you're not a mega-health system such as Kaiser or a University, you're basically getting screwed out of being in business with more and more layers of government regulation. Only the largest players will survive. What about the small primary care clinics, the rural docs, or God forbid--someone in solo practice. It's nearly impossible to stay in compliance with everything.

Government regulation of health care has become like the intrusive computer security software suites of today: well-intended but aggressive and misguided in their tactics to the point that the very systems they were designed to protect become unusable.

It seems our pharmacist friend has a fair amount of frustration in his line of work.

I suspect, though, that we're all trying to accomplish the same goal: cost efficient, high quality, private and secure health care.

I don't think, however, that it is an unreasonable goal that we could achievea secure 100% electronic prescribing system.

Heck, last month I completed an entirely electronic and phone transaction in which I rolled over 10 years of 401k retirement savings. Everything I'd saved was liquidated and sent by check via UPS to be reinvested a bunch of new mutual funds. No specialpaper. No signatures.

Certainly, if I can do this, I should be able to prescribe some Diovan without special paper.

Thanks, Wes, for fighting the good fight. Without rabble rousers like you, there would be no progress.

So, let me see if I've got this right. A pharmacist has to take time out of his/her busy day to clean up the mess made by the prescribing doc who can't/won't follow the rules. The doc knows what the rules are, he just doesn't waaaahhhhhna follow 'em because he doesn't like 'em, for whatever reasons.

Meanwhile, off in the corner is the patient (oh, you remember that bit player in this scenario, don't you?), who has to wait while an unnecessary additional step is added to getting her prescription. The pharmacist apologizes saying "I have to reach the doc before I can fill this." Perhaps someone at the pharmacy counter relays the message to the patient--the patient gets frustrated with yet another example of useless administrivia, and goes home to wait for all the players to do their thing.

Perhaps that patient does not have a way to come back any time soon to pick up the rx. Perhaps the patient does not have the time to wait while this phone call is made, or feels too lousy to wait in the busy store full of holiday shoppers. Perhaps, if that patient is me, I go home and say "screw it, it couldn't have been too important a medication if my doc couldn't even write the prescription correctly. Maybe I'll pick it up next week, maybe I won't."

So doc, what have you done today for your patients with your "I shouldn't have to use the correct rx paper" hissy fit?

P.S. If your business office needs wavy paper to process getting reimbursements, will that be too much work to get in place? Yes, getting paid is important, I am not belittling that; but getting patients their meds without extra hassles that could be prevented is important too, no?

Also, as the patient, if I know the rules and reqs ("take this medicine, stick to this diet, follow this exercise program," etc.) but decide I don't want to, even if I know the consequences, I am labeled "noncompliant." Most docs I know are not happy with their noncompliant pts. Some of them even grouse about them (anonymously)on their blogs. See any connections?

what do you guys do when e-prescribing goes down? is there a mechanism that notifies the sending docs that the prescriptions have not been received at the pharmacy?

on a semi-related note, i am at my hospital now which has an expensive emr. it has been down for 4 hours. i ask dr wes to post some thoughts on how to handle hospital emr going down and still function safely. 'emr plan b' i'm not a blogger or i would do it myself, but it might be along the lines of:

what do you guys do when hospital emr goes down? we've been down for over 4 hours now. we are totally paperless. i can't review what's happened to patients vital signs, i can't review previous notes or consults from other docs. i can't review meds given in hospital or other orders, or see clinic notes--and yes some of my consults are on intubated/sedated patients or confused patients who can't provide their own history-before you mock me mercilessly.

the jc(aho) has recently cracked down on us and now we have to do pre-procedure notes and postprocedure notes in addition to procedure notes. the rationale for the postprocedure note was in case someone else needed to know urgently what was going on with the patient before the procedure note was dictated. ha! that assumes 100% time working emr.

will the jc now require completely 100% up time with redundant computer systems, backup systems as part of the emr conversion? or else mandate 100% paper backup for the emr 100% of the time?

Stop being robots, the point of the post is the logrythmic expansion of regs is driving the little guy out of business and rendering the providers in the larger organizations bereft of any joy or motivation. Those who responded to this post with "just shut up and do it" don't or can't understand that if I slavishly complied with every regulation that comes my way, I couldn't even cover half my overhead. The solution for me was cash only low volume low overhead practice, of course the downside is that I can only accept a sixth of the folks I used to in my practice. But who cares it's easy to find a doctor, isn't it.

For those of you considering med school, make sure it is a true calling, then plan your training so you can practice outside the US,

for those of you burned out regulation lovers.....get a job at the DMV

About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.